The Basics of Outbreak

Investigation

Indonesia

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December 19, 2012
 Outbreak
 Definition (narrow)
• Incidence of healthcare-associated
infection is above the usual background
rate in the organization or
• Unusual microbe is emerging in a
significant number of patients

 Hospital, communities, regions, country, or

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global
 Outbreak
 Goal
• To identify the scope, severity, and contributing
factor(s) and to stop, limit, or reduce the
occurrences as soon as possible and
• To prevent further occurrences in the future
 Factors
– Patient population, locations, procedures, providers,
– Pathogens
– External factors (community, common source, etc.)

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 Epidemic curve depicting
patients with Norovirus
10
infection
9

8
7 7
Number of Patients

6
6
5

4 4
4
3 3 3

2
2
1 1 1

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0
December January February March April

Dec 2011 – April 2012

 Clinical presentation of patients
with Norovirus infection
53
(96%)

50
41
(75%)
40 36
(65%)

30

20
(37%)
20
12
(22%)
10
( )

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0
diarrhea nausea vomit abdominal fever
pain
 Time between onset of
symptoms and hospitalization
20
18

15
Frequency

10
9

5
4
3 3

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2 2 2
1 1 1 1
0
-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8

Time between onset of Symptoms and Hospitalization in days

 Length of stay: Community
acquired vs. Nosocomial

20

15

10
Days
5

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*p<0.001
0
Community Acquired Hospital Acquired
(3.4 ± 2.1 days) (9.3 ± 4.8 days)
 Global Outbreak
 Influenza
– 1918 (Pandemic)
– Many epidemics
 SARS (Severe Acute Respiratory Syndrome)

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 Global Outbreaks
 H1N1 (swine or novel) of 2009

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 National Outbreak
 Fungal Meningitis in the USA (2012)
Source – contaminated injectable methylprednisolone

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 Outbreak Investigation
 Recognition of a potential outbreak (Surveillance)
1. Prepare for the investigation
2. Confirm that an outbreak exists - announce!
3. Identify agent (diagnosis)
4. Line listing, collect critical data, collect specimen
5. Person, place, and time – characterize the cases
6. Share the information widely

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7. Action with immediate control/prevention measures
 Outbreak Investigation
8. Form hypothesis based on the observation
• source, reservoir, mode of transmission
9. Test hypothesis (commercial product)
10. Plan an additional study
11. Refine surveillance, specimen collection methods
(patient, environment, processing, turn-around-
time, etc.)
12. Prevention and control guideline
13. Summary (written report, information sharing, and

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report to authority)
 Let us practice

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Common source: Point exposure
(food poisoning)

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Propagated source with secondary and
tertiary cases

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Common source with intermittent
exposures

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Final Report of Outbreak: Sample
SAMPLE

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